MRONJ

Question 1

What is MRONJ?

Answer 1

Medication related osteonecrosis of the jaw

• caused by medication that leads to necrosis and death of the bone
• exposed or non healing bone present for more than 8 weeks
• the drugs that cause this reduce bone turnover and accumulate in sites of high bone turnover such as the jaw

Question 2

What are the symptoms of MRONJ?

Answer 2

• may be asymptomatic but may have pain, numbness, swelling or tingling
• patient must be on an anti respective, anti angiogenic or rank-l inhibitor medication
• no history of radiation (osteoradionecrosis)

Question 3

What is the incidence of MRONJ?

Answer 3

0.01-0.001% in non malignant disease of bone

1% in malignant disease - multiple myeloma, prostate cancer

Question 4

What are the anti resorptive drugs that cause MRONJ?

Answer 4

Bisphosphonates

• alendronic acid, risedronate sodium
• inhibits osteoclasts action to reduce bone remodelling

Question 5

What are the RANKL inhibitors that cause MRONJ?

Answer 5

Denosumab
= monoclonal antibody which inhibits osteoclasts function and resulting bone resorption
- not effective 9 months after Tx completion as does not bind to bone

Question 6

What are the anti angiogenic drugs that cause MRONJ?

Answer 6

Bevacizumab
- drugs that target new blood vessel formation process to restrict vascularisation of tumours used in Tx of metastatic cancers.

Question 7

Who would you class as a low risk MRONJ patient?

Answer 7

• Pts being treated for osteoporosis or non malignant diseases
• oral bisphosphonates or quarterly/yearly infusion of IV bisphosphonates for less than 5yrs
• not concurrently being treated with systemic glucocorticoids

Question 8

Who would you class as a high risk MRONJ patient?

Answer 8

• Pts being treated for osteoporosis or non malignant disease with oral bisphosphonates or quarterly/yearly IV transfusions of bisphosphonates for more than 5yrs
• Pts treated with concurrent glucocorticoids - Pts being treated with anti-resorptive or anti angiogenic drugs as part of cancer management
• Pts with previous MRONJ diagnosis

Question 9

If at risk patient has non healing socket at 8 weeks how do you manage this?

Answer 9

Discuss the probability that MRONJ has occurred and refer to specialist oral surgeon
Also report on MHRA yellow card scheme.

Question 10

A patient presents with severe pain from a grossly carious unrestorable 36. The tooth requires XLA. The patient is on prednisolone, alendronic acid and rampiril. What is the best course of action of management?

Answer 10

• discuss the risk of MRONJ with patient and gain valid content and either extract tooth or refer to secondary care for extraction if they are higher risk.